This document describes the experience of a 75-year-old man named John who has been taking warfarin for 10 years to treat atrial fibrillation. It notes that it took 8-12 weeks for his INR levels to stabilize through dietary adjustments when he started warfarin. For the last 5 years, John has been monitoring his INR at home every 4-6 weeks and his levels have remained between 2-3 without any serious issues. The document states that John's atrial fibrillation and anticoagulation therapy have not significantly impacted his lifestyle.

1. A Patient’s Voice
John’s* perspective is shared in each section.
John is a 75-year-old retired surgeon with atrial fibrillation who has been taking
warfarin for 10 years. John also has gout and arthritis and a stent for which he takes
baby aspirin.
When he initially started warfarin, it took about 8 to 12 weeks to stabilize his INR
within therapeutic range, mainly through dietary adjustments.
For the last 5 years, John has been using a home INR kit every 4 to 6 weeks and
submits the results through an automated system to his physician. His INR has
remained mostly between 2 and 3 and has never exceeded a low of 1.8 or high
of 4.3.
John’s atrial fibrillation and anticoagulation therapy have not significantly impacted
his family or required him to change his lifestyle.
*Not the patient’s real name.

2. A Patient’s Voice
Patients may not be aware of the different types of atrial fibrillation—educate them.
Educate your patients that anticoagulation is critical, but it is just one aspect
of managing atrial fibrillation.
Resources and Tools
During atrial fibrillation,
a blood clot can form
in the left atrium of the
heart. If a piece of the
clot breaks off and
travels to an artery in
the brain, it can block
blood flow, causing
a stroke.
Affected portion of the brain
Embolus blocks blood
flow to part of the brain
Internal carotid artery
Common carotid artery
Embolus (clot)
Aorta
NHLBI. Available at: http://www.nhlbi.nih.gov/health/healthtopics/topics/af/signs.html.
Atrial fibrillation
in the left atrium
Thrombus (clot)
Heart

3. A Patient’s Voice
John’s CHADS2 score is 1 (due to his age).
Empower your patients by educating them on CHADS2.
Resources and Tools Available at TEAManticoag.com

4. A Patient’s Voice
“It’s so much more important to prevent stroke than to reduce bleeds.”
For John, the bleeding concern has been quite benign. As a surgeon, he was more
worried about his patients bleeding. He believes his physiological makeup makes
him less prone to bruising and bleeding.
Resources and Tools Available at TEAManticoag.com

5. Resources and Tools
Generic/Trade Name Identification Guide for Drugs Mentioned in Activity
Generic Name
Trade Name*
apixaban
Eliquis®
clopidogrel
Plavix®
dabigatran etexilate
Pradaxa®
diltiazem
Cardizem®, Dilacor®, Tiazac®
prasugrel
Effient®
rifampin
Rifadin®
rivaroxaban
Xarelto®
ticagrelor
Brilinta®
ticlopidine
Ticlid®
verapamil
Calan®, Verelan®, Verelan® PM, Isoptin®, Isoptin® SR, Covera-HS®
warfarin
Coumadin®, Jantoven®
*For identification purposes only; does not imply endorsement.

6. Resources and Tools
Warfarin and Novel Anticoagulant Mechanisms of Action
XII
XI
IX
VIII
Unfractionated
Heparin
VII
X
Low-MolecularWeight Heparin
V
II
I
Fibrin Clot
Courtesy of David Garcia, MD.
New Oral
Xa Inhibitors
Rivaroxaban
Apixaban
Edoxaban
Warfarin
New Oral
IIa Inhibitor
Dabigatran etexilate

7. A Patient’s Voice
John’s physician offered him a new anticoagulant, but John decided to stay with
warfarin because it is:
Working for him (it is preventing strokes)
Cost effective (he does at-home INR testing)
Reversible (at his age, he is at greater bleed risk and it is harder to reverse with the
newer anticoagulants)
Advice for a new patient
who will begin warfarin
“To be successful on warfarin, the patient needs to be reliable.”
“Take the medication as directed regularly, modify diet as needed to
keep dosage in range, and if able and responsible, get your own INR kit
for testing.”
Diet and warfarin
“Get the dietary thing squared away up front. Once you are rock solid with the
diet, maintaining the medication is a lot easier.”
“I love veggies but have reduced leafy vegetables to minimize excess vitamin
K to keep INR in range.”

8. Resources and Tools Available at TEAManticoag.com

9. A Patient’s Voice
John believes cost is important to discuss with patients, including:
Approximate monthly cost of being on warfarin vs newer drugs
Cost of INR testing in office or at home
Practical ways to obtain medication (retail pharmacy vs hospital, mail order, manufacturer’s patient assistance
program, etc)
John travels often and lives in 3 different locations each year. He monitors his INR using a home kit.
“For someone with reasonable education and background, these kits sure simplify travel time and
specimen blood collection and reporting costs.”
John believes reversibility is important to discuss with patients.
John has never had a nosebleed while on warfarin.
Resources and Tools
Visit the Anticoagulation Forum (acforum.org) to find anticoagulation clinic locations.

10. A Patient’s Voice
Use pamphlets, comic book-like brochures, or new apps to educate patients on strokes
and anticoagulation.
John believes the seriousness of a stroke is so important that if patients resist anticoagulation
therapy, the physician should have them sign a release (as Dr. Flores suggests).
Resources and Tools Available at TEAManticoag.com
Patient handout

11. A Patient’s Voice
John has not interrupted anticoagulation for dental procedures, but when John’s stent
was placed, he was off warfarin for a couple days and bridged with heparin.
Resources and Tools Available at TEAManticoag.com
Switching From Warfarin: How?
Dabigatran
Switch when INR ≤2
Rivaroxaban
Switch when INR <3
Apixaban
Switch when INR <2

12. Performance Improvement
CME Activities Also
Available at
TEAManticoag.com

13. Proceed to Posttest
and Evaluation
Close the video and return to Medscape to access